• Quality Rated childcare programs and social determinants of health in rural and nonrural Georgia

      Webb, Nancy C.; Gates, Madison L.; Augusta University (Georgia Public Health Association, 2016)
      Background: Early childhood is linked to school readiness and early school achievement. Through its Quality Rated (QR) program, which was designed to improve the quality of care in early childhood programs, the state of Georgia has been a trailblazer in funding universal preschool and in improving the quality of childcare programs. We have assessed differences in the availability of QR childcare programs in Georgia to learn if, in rural versus non-rural counties, there is a relationship between QR childcare programs and health-related outcomes. Methods: This cross-sectional study evaluated county-level data to evaluate the relationship between QR childcare programs and social determinants of health. County-level data for Georgia were extracted from the Georgia Department of Early Care and Learning, County Health Rankings and Roadmaps, and the Georgia Juvenile Justice Data Clearinghouse. Results: Counties without QR childcare programs had child mortality rates 3.5 times higher than those for the state overall. Other differences in health-related outcomes included, but were not limited to, teen birth rates, low birth-weight babies, children in poverty, housing problems, and food insecurity. Conclusions: It is now appropriate to address the prevalence of health disparities in rural areas of Georgia and focus on some of the disparities through the QR early childhood programs and other state agencies. Empowering rural communities to address health disparities may be the most favorable path toward diminishing these inequalities.
    • Characteristics of rural users of emergency medical services in Georgia: A populationbased study

      Turner, Nannette; Chen, Huey; Morosanu, Liliana; Mercer University (Georgia Public Health Association, 2016)
      Background: Emergency medical services (EMS) are an essential part of health care. Appropriate information about EMS usage in rural areas will allow effective utilization of EMS resources for their intended purpose, and at the state level, drive the adoption of better EMS policies to ensure and maintain equitable access to these health services in rural areas. Methods: The present study, performed by analyzing data from the Georgia Emergency Medical Services Information System (GEMSIS), describes the population using EMS in rural Georgia. Distributions of rural EMS transports are reported, along with usage for selected population groups based on race, gender, age groups, and primary impressions recorded by emergency medical personnel (EMP). Results: The groups with the highest rates of EMS use were African Americans, females, and the elderly. In 2014, about twice as many African Americans used EMS as compared to Whites. Rural use of EMS increased with age, with the elderly having the highest percentage of users. About 31% of all transports were for emergency conditions; the remaining 69% were for non-emergencies. The most frequent health complaints were those for altered physical conditions and traumatic injuries. Conclusions: The findings of this study can guide decision in planning future services and ensuring appropriate access to EMS in rural Georgia.
    • Implementation and evaluation of the Carrera Program for delaying teen sex in Georgia

      Tucker, Tressa; Langley, Mary; Morehouse School of Medicine (Georgia Public Health Association, 2016)
      Background: In three geographic areas in Georgia, rural, micropolitan, and urban, Morehouse School of Medicine (MSM) implemented the evidence-based Children’s Aid Society Carrera Program at community organizations with Boys and Girls Clubs (BGCs) as the comparison group. This study attempted to replicate the findings of reduced teen pregnancy and birth found for the New York Carrera Program. Methods: For this longitudinal study with a quasi-experimental design, the sample included 400 youth who were in 6th or 7th grade. A total of 220 were enrolled in the intervention group and 180 in the comparison group. The study was performed in the fall of 2012, 2013, and 2014. The following data sources were utilized: paper-and-pencil surveys, daily attendance, component attendance, observation forms, focus groups, and interviews. There was one analytic sample (N = 204) for the primary research questions. Data were pooled separately across the intervention and the comparison sites. A hierarchical logistic regression model was used to test for program impact. Covariates included selected demographic variables, site geography (urban vs. rural), and previous sexual history. For answering the two primary research questions the 0.025 significance level was used to adjust for multiple comparisons. Results: After one year of the intervention, the Carrera group was significantly lower in “ever had sex” than the BGC group. At years two and three, however, there were no appreciable differences between these two groups, a result possibly due to implementation issues, particularly attendance. Conclusions: When implemented with fidelity, Carrera can have a positive effect, even in rural communities. Programs should seek to achieve the required intervention dosage and address the reasons why teen pregnancy is often higher in these communities.
    • Human papillomavirus-associated cancers in Georgia, 2008-2012

      Solomon, Irene; McNamarea, Chrissy; Bayakly, Rana A (Georgia Public Health Association, 2016)
      Background: High-risk human papillomaviruses (HPV) cause most anal, vaginal, vulvar, penile, and oropharyngeal cancers, and virtually all cervical cancers. In 2014, in Georgia (GA), fewer than half of adolescent females and males aged 13-17 years received the three doses of the HPV vaccine. Increasing vaccination coverage among this age group, education of adolescents in regard to HPV risks, and cervical cancer screening of adults can prevent HPV-associated cancers. Methods: The incidence of HPV-associated cancers for 2008-2012 in GA was obtained from GA Comprehensive Cancer Registry data. Case definitions for HPV-associated cancers were based on standard definitions of the Centers for Disease Control and Prevention (CDC). Data for anatomic sites known to have HPV-associated cancers, including the cervix, vulva, vagina, penis, anus, and oropharynx, were analyzed. Also derived were ageadjusted rates, age-specific incidence rates, the percentage of each cancer found attributable to HPV, and ageadjusted incidence rates by geography. Results: During 2008-2012, a total of 6,056 HPV-associated cancers were diagnosed (males, 2,408; females, 3,648). Of these, 4,629 cancers were attributable to HPV (males, 1,574; females, 3,055). The most common cancers attributable to HPV were oropharyngeal cancers among males (1,182); and cervical cancers (1,862) among females. Females living in smaller urban counties had a higher cervical cancer incidence rate than females living in metropolitan counties and metro areas (1 million or more population). Males living in rural counties had a lower oropharyngeal cancer incidence compared to the state incidence rate. Conclusions: Since HPV vaccination at age 11-12 years can prevent HPV-related cancers in adulthood, clinicians should promote HPV vaccination along with routine immunizations to adolescents. Surveillance of HPVassociated cancers using GA cancer registry data is needed to track future changes in incidence data due to administering the HPV vaccine, increasing cervical cancer screening, and educating youth in GA about HPV risk factors.
    • A systematic review of lifestyle interventions for chronic diseases in rural communities

      Smith, A Selina; Ansa, Benjamin; Augusta University (Georgia Public Health Association, 2016)
      Background: Rural Americans suffer disproportionately from lifestyle-related chronic diseases (e.g., obesity, diabetes, hypertension, cardiovascular disease, and breast cancer). Interventions that consider the distinctive characteristics of rural communities (e.g., access to healthcare, income, and education) are needed. As an initial step in planning future research, we completed a systematic review of dietary intake and physical activity interventions targeting rural populations. Methods: Manuscripts focused on dietary intake and physical activity and published through March 15, 2016, were identified by use of PubMed and CINAHL databases and MeSH terms and keyword searches. Results: A total of 18 studies met the inclusion criteria. Six involved randomized controlled trials; 7 used quasi-experimental designs; 4 had a pre-/post-design; and 1 was an observational study. Eight studies were multi-site (or multi-county), and 3 focused on churches. Primary emphasis by racial/ethnic group included: African Americans (6); Whites (2); Hispanics (3); and two or more groups (7). Most studies (17) sampled adults; one included children. Two studies targeted families. Conclusions: Additional lifestyle intervention research is needed to identify effective approaches promoting healthy diet and exercise and chronic disease prevention in rural communities. Studies that include rigorous designs, adequate sample sizes, and generalizable results are needed to overcome the limitations of published studies.
    • Leveraging university-community partnerships in rural Georgia: A community health needs assessment template for hospitals

      Robinson, Ayanna; Cherry, T Sabrina; Elliott, Michelle; Davis, Marsha; Bagwell, Grace; University of Georgia (Georgia Public Health Association, 2016)
      Background: Under the Affordable Care Act, nonprofit hospitals are required to conduct a Community Health Needs Assessment (CHNA) every three years. Using recommendations proposed by Georgia Watch, students and faculty members from the University of Georgia (UGA) conducted a CHNA for a hospital in a rural county in Georgia. The purpose of the CHNA was to identify community health problems and needs, as well as community assets and resources. The aim of this report is to describe the process for conducting the CHNA, the findings, and the lessons learned. Methods: The CHNA team consisted of students and faculty members from UGA’s College of Public Health and a Public Service and Outreach professional who worked in the community. In completing the CHNA, the team used the following fivestep process: define community, collect secondary data on community health, gather community input and collect primary data, prioritize community health needs, and implement strategies to address community health needs. Primary and secondary data were collected. Results: By triangulating findings across data sources, the CHNA team created a community health profile for the service area of the hospital. Based on these findings, the community identified four main areas for improvement, prioritized these health issues, and developed an implementation strategy for the hospital and community. Conclusions: The process used to conduct this CHNA can serve as a model for other rural communities undergoing similar assessments. Lessons learned from completing this CHNA can be applied to future CHNA efforts.
    • The two Georgias: Disparities in rural health and healthcare

      Nelson, D Gary; Healthcare Georgia Foundation (Georgia Public Health Association, 2016)
    • Using the Exercise is Medicine® on Campus platform to assess college students’ practice of physical activity in a rural setting

      Melton, Bridget; Williamson, A Jazmin; Bland, Helen; Zhang, Jian; Georgia Southern University (Georgia Public Health Association, 2016)
      Background: The college setting offers public health educators and exercise scientists a favorable environment to implement wide-spread change in levels of physical activities. With over two-thirds of all adults in the U.S. now categorized as obese or overweight (CDC, 2015), it has become necessary to increase physical activity levels on college campuses. Exercise is Medicine® on Campus (EIM®-OC) is a national initiative to increase physical activity on college campuses by creating an environment to change the subjective norm of diminished exercise movement and fitness among adults. The purpose of the present study was to use the EIM®-OC platform to assess college students’ beliefs and practices of physical activity by implementing this program in a rural setting. Methods: Implementation of EIM®-OC was conducted over a one-week period. More than 1,000 participants joined in the events led by a multi-disciplinary team. Data collected included self-reported daily physical activities, campus commuting, and level of exercise intensity. Descriptive statistics and chi-square reported frequencies and statistical differences. Results: Overall, the campus turnout for EIM®-OC events was 7.6% higher than national norms. Physical inactivity was statistically different between racial groups (P=0.04). Males reported engagement in physical activity primarily for enjoyment and social interactions. Active transport was lower in the rural community than in urban counterparts. Conclusions: Findings from this study described the successful engagement of a midsized rural campus population in an EIM®-OC campaign. The study revealed self-reported physical activity patterns of students comparable to national averages; however there was a disproportionate number of African Americans who did not participate in any vigorous physical activity.
    • Georgia Latino enrollment in the Affordable Care Act: A qualitative, key informant analysis

      McCulloch, Audrey; Evans, P Dabney; Emory University (Georgia Public Health Association, 2016)
      Background: Prior to implementation of the Affordable Care Act (ACA) in 2010, one in three Latinos in the United States were uninsured. In Georgia, a state that established a federal Marketplace, nearly half of Latinos lacked health insurance coverage going into the initial enrollment period of October 1, 2013 to April 15, 2014. The ACA provided an opportunity for these uninsured Latinos to gain health insurance coverage, thus increasing their access to necessary medical services. The purpose of this qualitative study was to explore, from the perspective of key informants, knowledge of Georgia Latinos about the ACA and perceived barriers to enrollment in Marketplace health insurance coverage. Methods: A semi-structured interview guide based on a review of relevant literature and consideration of the study goal and aims was developed. Fourteen in-depth interviews with key informants (participants) from Georgia’s Latino community, including nonprofit leaders, health media professionals, and community health promoters, were conducted between June and September 2014. Results: Participants described perceived barriers to enrollment during the initial ACA enrollment period and made recommendations for the design and implementation of future outreach, education and enrollment strategies. Major themes that emerged involved basic health literacy, misinformation, enrollment opportunities, the importance of place and politics, and technology and language as barriers. Conclusions: To target Georgia Latinos, we provide seven recommendations for outreach, education and enrollment, including the organization of one-on-one services in locations of familiarity and comfort to Georgia Latinos and the hiring and training of Spanish-speaking enrollment professionals. When providing ACA education to Latinos, stakeholders should begin with basic health literacy concepts and education regarding the fundamentals of the United States health insurance system. The findings of this study may serve to guide future design and provision of culturally competent outreach, education and enrollment services.
    • Engaging rural Georgians in Internal Revenue Service (IRS)-mandated community health needs assessments

      Lawrence, H Raymona; Nazaruk, Dziyana; Denis-Luque, Marie; Tedders, Stuart H.; Georgia Southern University, Georgia College and State University (Georgia Public Health Association, 2016)
      ABSTRACT Background: On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law. The law became effective on March 23, 2012. The ACA stipulates that non-profit hospitals must demonstrate benefit to their communities through the process of community health needs assessments (CHNAs). Failure to comply with this law may result in loss of non-profit status or large fines. This report describes strategies for engaging rural communities in Internal Revenue Service (IRS)-mandated CHNAs. Methods: Public health practitioners from Georgia Southern University’s Jiann Ping Hsu College of Public Health collaborated with 18 rural, non-profit hospitals to complete community-specific CHNAs. Quantitative and qualitative data were gathered from primary and secondary data sources to provide a comprehensive assessment of the needs and the assets of each of the communities. Results: The project team assisted 18 rural, non-profit hospitals in assessing the needs of their communities. Technical reports provided to the hospitals described the issues discovered during the assessment. Hospitals were empowered to utilize the information to prioritize community- specific issues and to develop comprehensive plans for implementation. Conclusions: The CHNA process provides an opportunity to strengthen relationships between public health services and hospitals as well as between hospitals and the communities they serve. Hospitals need to identify and engage diverse sectors of the community in order to comprehensively assess the needs and assets of communities to address the social determinants of health and to reduce health inequities/disparities.
    • Capital and technical assistance needs of Georgia’s health-related nonprofits: An exploratory study

      Daniel, Jerry B.; Green-Caldwell, Cherysh; Albany State University, Turner County Connection-Communities In Schools of Turner County, Inc. (Georgia Public Health Association, 2016)
      Background: Nonprofit organizations, particularly those related to health and human services, are involved in addressing needs of the American population. They provide an array of services in small and large communities throughout the United States. Compared to for-profit organizations, health-related nonprofits are increasing in number. Despite having a substantial share of the health care market, nonprofit organizations face difficulties delivering services to those in need. The difficulties faced by rural nonprofits may be greater than those for their urban counterparts. The impetus for this study came from Healthcare Georgia Foundation’s goal of strengthening nonprofits to address the burgeoning health inequities in Georgia. The purpose was to gain a better understanding of the capital and technical assistance needs of health-related nonprofits. The specific aim was to answer a set of exploratory questions. Methods: This study utilized exploratory, descriptive methodology to examine the capital and technical assistance needs of health-related nonprofits in the state of Georgia. Organizational management staff was used as the unit of analysis. A cross-sectional, correlational design was used to gauge participants’ views about their organization’s current needs. The sample consisted of 48 rural and 45 urban/metropolitan nonprofits. Results: The findings provide information related to the capital and technical assistance needs of rural and urban health-related nonprofits in Georgia and reveal specific needs of nonprofits focusing on health and social services. Conclusions: The results have public health implications for a state that currently faces various public health challenges. Nonprofits located in rural areas could use more technical assistance in reaching their funding goals.
    • Demographic and socioeconomic factors associated with HPV vaccination in Georgia’s South Central Health District

      Ekeledo, Sydney; Best, Candace; Norman, Stephanie; Bazemore, Jodi; Schwind, Jessica Smith; Augusta University, South Central Health District (Georgia Public Health Association, 2016)
      Background: Human Papillomavirus (HPV) subtypes are the primary cause of cervical cancer. Despite introduction of the HPV vaccine in 2006, vaccination percentages remain low across Georgia counties. The primary objective of this research was to conduct a descriptive epidemiological study of HPV vaccination coverage among individuals in the South Central Health District (SCHD) to provide guidance for targeted vaccination campaigns aimed at adolescents residing in rural communities. Methods: Data from the Georgia Registry of Immunization Transactions and Services and AEGIS.net, Inc. were used to analyze demographic and socioeconomic factors associated with HPV vaccine uptake among individuals visiting county health departments in the SCHD from 2007-2014. Descriptive statistics were used to evaluate the relationship between sex, age at first vaccination, county of vaccine administration, race, and insurance status to vaccine series completion. Results: In the SCHD, Johnson County had the highest completion percentage (50%); Montgomery County had the lowest (20%). However, Montgomery County had the fastest time to completion (334 days). Throughout the district, males were fully vaccinated at much lower percentages than females (p < 0.001). Race was a significant variable (p=0.011) for vaccine completion. Compared to other racial groups, more White individuals completed the HPV vaccine. Absolute counts of HPV vaccine doses peaked in the study population during 2010 (n=507). Conclusions: Due to overall low rates, community-based intervention methods should be considered to increase HPV vaccine uptake across the SCHD. School-based programs may be useful in targeting at-risk populations and increasing rates of HPV vaccine initiation and completion. Expanded efforts are needed to determine the best structure for effective school-based programs.
    • Improving rural access to care: Recommendations for Georgia’s health care safety net

      Minyard, Karen; Parker, Chris; Butts, John; Georgia State University (Georgia Public Health Association, 2016)
      Background: In Georgia, the safety net provides health care services to vulnerable populations scattered across 74 urban and 85 rural counties. In rural communities, the safety net is challenged with longstanding gaps in service provision and persistent difficulty in making services accessible. The rural safety net in Georgia is vulnerable. Methods: An environmental scan was conducted of the Georgia rural safety net to assess who it serves, its providers, and how care is accessed in light of the Affordable Care Act (ACA). The scan included analysis of population-based census and health databases and a literature review to inform recommendations. Results: The population served by the rural safety net is typically older, poorer, and less healthy than the population in urban areas. The principal providers of care in the rural safety net are community hospitals, federally sponsored and free or charitable clinics, and some health departments. While the ACA provides an opportunity to increase insurance coverage and access to care, it poses a financial challenge to providers of the rural health safety net. As the health system evolves, the rural health safety net must adapt to shifting priorities and patient populations. Conclusions: To enhance the sustainability of the rural safety net, it is necessary for providers to focus on coordination of care through integration of services and broader health system partnerships. Providers of the Georgia rural safety net and stakeholders should focus on (a) ensuring a comprehensive assessment of all components of the safety net, (b) facilitating change through high-performing health departments and community-based organizations, (c) funding efforts to provide patient-centered medical homes for the rural uninsured, (d) emphasizing the value of technology in the provision of care and information/data exchange, and (e) rewarding innovations in rural and safety net workforce development and deployment.
    • A comparison of hospital utilization in urban and rural areas of South Carolina

      Dicks, Vivian; Augusta University (Georgia Public Health Association, 2016)
      Background: Previous studies have described health care utilization based on insurance status and ethnicity. Few investigations, however, have looked at rural populations in relation to distance in securing health care. Methods: The 2008 to 2009 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for South Carolina was used to assess the relationship of living in rural versus urban communities and the demographic variables related to insurance coverage. By use of bivariate and multivariate analyses, patient socio-demographic characteristics were explored for working-aged groups in relation to their income and for payer status (Medicaid or uninsured) relative to those privately insured. Results: Of hospitalizations, 68.89% were for those living in urban areas, 20.52% in large rural areas, 6.57% small rural areas, and 4.02% in isolated rural areas. Blacks lived predominantly in small rural (53.65%) and isolated rural communities (51.55%). As income decreased, the percentage of hospital admissions increased, from 5.83% for those earning $66,000 to 43.29% for those earning between $1 and $39,999. Conclusions: Hospital admissions may not be entirely dependent on race, income or insurance, but could also be influenced by geographic access. Further, having private insurance, higher incomes, and living in urban areas are positive predictors for better health outcomes.
    • Georgia’s rural hospital closures: The common-good approach to ethical decision-making

      Bastian G., Randi; Garner, Marcus; Barron S., John; Akowuah A., Emmanuel; Mase A. William; Jiann-Ping Hsu College of Public Health, Department of Health Policy and Management, Georgia Southern University (2016)
      ABSTRACT Background: Critical access hospitals provide several essential services to local communities. Along with the functions associated with providing necessary medical care, they also offer employment opportunities and other economic benefits to the communities they serve. Since 2010, the number of rural hospitals closures has steadily increased. The common-good approach to ethical decision-making provides a framework that aids in evaluation of the effects that hospital closures have on rural residents and communities. Methods: This analysis includes results of a systematic overview of peer-reviewed literature to address the following research questions: 1) How have state policies and the adoption of Medicaid expansion influenced the viability or rural hospitals? 2) What are the ethical implications of Medicaid expansion and state policy reform/adoption pertaining to viability of rural hospitals? and 3) What are the ethical implications of critical access hospitals closures on rural communities in Georgia? Information related to these questions is presented, along with tactics to addressing these in an ethical manner. Results: This descriptive analysis shows that the largest number of state-specific closures have occurred in states with a federal exchange and which chose not to expand Medicaid. Characteristics of the state of Georgia and the counties with recent closures show that these counties typically have smaller populations with a high minority presence, lower education and income levels, and higher numbers of medically uninsured. Conclusions: The common-good approach to ethical decision-making is suitable for evaluating the ethical implications of policy-level decisions impacting the closure of critical access hospitals serving the rural communities of Georgia.